Middle and Anterior Compartment: Issues for the Colorectal Surgeon
Multi-compartment pelvic floor disorders are common and require a multidisciplinary team approach to evaluation and management. It is imperative for specialists to recognize when consultation with the one another is indicated, as joint management may significantly improve patient outcomes. Pelvic floor surgeons must have a good grasp of pelvic floor anatomy and understand the relationships between pelvic organs and the connective tissue structures that support them. Evaluation of pelvic organ prolapse includes a thorough physical examination including the POP-Q exam and urodynamics in many cases. There is no role for routine imaging in the evaluation of pelvic organ prolapse, with the exception of the diagnosis of some posterior compartment defects. Pelvic organ prolapse can occur in the anterior, apical, and posterior compartments and can be surgically repaired using either a transvaginal or transabdominal route. Transvaginal surgery includes cystocele repair, extraperitoneal or intraperitoneal colpopexy, and obliterative procedures. These can be performed at the time of transperineal rectal procedures performed by the colorectal surgeon. Transabdominal procedures can be performed via the open approach but can also be done laparoscopically or robotically. Sacral colpopexy is a common abdominal procedure performed for apical vaginal prolapse, and the procedure can be performed concomitantly with ventral or other forms of rectopexy in patients with rectal prolapse or intussusception. Patients with a rectocele may or may not have associated defecatory dysfunction. The rectocele can be repaired either transvaginally or transanally, and different indications exist for each procedure. The transvaginal approach is more common and seems to have better outcomes and is associated with less morbidity.